Telemedicine May Work for Headache Visits

Using telemedicine to diagnose and treat non-acute headache is as safe and effective as a traditional consultation, according to a non-inferiority study conducted in Norway.

In a randomized trial, there were no differences in Headache Impact Test-6 (HIT-6) scores or Visual Analog Pain Scale (VAS) scores at 3 or 12 months whether patients saw a neurologist in person or via video conference, reported Kai Müller, MD, of the Arctic University of Norway in Tromsø, and colleagues.

Action Points

Note that this randomized trial from Norway suggested that telemedicine visits for non-acute headaches may be as effective as in-person neurology visits in terms of pain scores at 3 and 12 months.

Be aware that telemedicine may not be as feasible in locations where secondary causes of headache are much more prevalent.

Nor were there any differences in the primary safety endpoint of secondary headache at one year, they wrote online in Neurology.

"Northern Norway covers a huge area and it is broken up by mountains, valleys and fjords into many sparsely populated places, so traveling to see a doctor can be cumbersome and expensive for many people," Müller said in a statement. "But telemedicine may be valuable for people all over the world who are suffering with headaches and want to see a specialist without any extra hassle or inconvenience."

The team conducted the study at the University Hospital of Northern Norway, which serves about 270,000 people, some of whom must travel by boat or plane from remote islands scattered throughout the arctic region. The 402 patients with non-acute headache enrolled in the study were referred from primary care to the hospital's neurology department between 2012 and 2015, and they were randomized to either a telemedicine or traditional consultation.

The researchers excluded patients who had seen a neurologist for headache management within the last two years. They also excluded patients with acute headaches (occurring less than four weeks before the referral), as well as those with radiologic or clinical abnormalities.

Müller and colleagues had assessed the same group of patients in an earlier study about the cost-effectiveness and acceptability of telemedicine. For the new study, they followed up with the same group at three and 12 months by mail or an online survey service.

Comparing the three periods, they did not find any significant differences between telemedicine and traditional consultations in HIT-6 (P=0.84) or VAS (P=0.64). Because they only found one secondary headache in each group, they estimated that the number needed to miss one secondary headache with the use of telemedicine was 20,200.

The authors noted that this risk estimate was reduced by excluding secondary headaches from the referrals as performed in clinical practice. Also, the relatively young age-range of the participants (the upper limit was 65) could have reduced the number of abnormalities found by neuroimaging. They also noted how telemedicine might be less safe in other geographic areas like South Nigeria, where CT scans revealed pathologic findings in as high as 50 percent of patients with nonacute headaches. Another limitation included the inherent inability to blind patients in a telemedicine trial.

Still, they concluded that telemedicine consultation for non-acute headache is as efficient and safe as a traditional consultation -- but some neurologists cautioned that details can be lost with telemedicine.

Neurologist David Rabinovici, MD, of New York Neurology Associates, noted that if neuroimaging is used in combination with telemetric consultations for headaches, "there are going to be very few cases you're going to miss. But you are going to miss some by not having a full consult."

He said subtle secondary cues that have contributed to his diagnoses required clear and unobstructed observation, which might be lost in a telemedicine consult. Asking a patient to remove chewing gum might reveal slight imperfections in speech; a peculiar odor could indicate an endocrine problem, he said.

Also, initial consultations often begin before the patient sits down in the examining room, and end after they leave for Rabinovici.

"I may even observe the patient a few minutes prior to him coming in without him or her knowing," said Rabinovici. "The way the patient moves, walks into the room, guards himself from the light, holds his head or neck, or sits in the room, can tell you a number of things about the severity of the headache. But tests like VAS are highly subjective."

David Charles, MD, chief medical officer of the Vanderbilt Neuroscience Institute and director of telemedicine at Vanderbilt University Medical Center, emphasized that doctors also need to take the patient's experience into account in deciding when to use telemedicine.

"For some medical conditions, the patient may actually prefer the televisit over the in-person visit," said Charles. "If it's the patient's preference, then the physician needs to know if it's medically appropriate to care for those problems via telemedicine. Here we have evidence that for this particular problem, telemedicine is perfectly fine to use."

Last Updated June 19, 2017

The study was supported by the Northern Norway Regional Health Authority.

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